Provider Demographics
NPI:1689672370
Name:TYSON, MICHELLE ASANTEWA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ASANTEWA
Last Name:TYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1412
Mailing Address - Country:US
Mailing Address - Phone:626-798-4952
Mailing Address - Fax:626-798-5260
Practice Address - Street 1:2661 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1412
Practice Address - Country:US
Practice Address - Phone:626-798-4952
Practice Address - Fax:626-798-5260
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H69207Medicare UPIN